521 Administration and Eligibility

521.1 General

 

Reference Note:

For more material on the information in 521.1, see:

The Office of Personnel Management (OPM) administers the Federal Employees Health Benefits (FEHB) Program. The FEHB law, policies and regulations issued by OPM, including those governing eligibility and benefits, are controlling in the event of conflict with these instructions.

521.2 Eligible Employees

 

Reference Note:

For more material on the information in 521.2 through 521.3, see:

The following employees are eligible for health insurance coverage:

  1. Officers in charge, except “off–the–street” officers in charge, as noted in 521.3a.
  2. Employees in the regular workforce expected to work at least 6 months each year.
  3. Employees with career appointments employed to serve under a cooperative work–study program that:
    1. Will be in existence at least 1 year.
    2. Requires the employee to be in pay status at least one–third of the total time required to complete the program.
  4. Student–trainees with career appointments serving under a formal cooperative work–study program that requires them to be in a pay status for at least one–third of the total time required to complete the program.
  5. Contract executives and others appointed by contract, provided:
    1. The contract requires personal services and covers a period in excess of 1 year.
    2. The individual is under the supervision and direction of the Postal Service.
    3. Work is performed on a full–time or specified part-time basis and the individual is paid on the basis of units of time.
  6. American nationals employed at Postal Service installations in American Samoa, Micronesia, and Guam.
  7. Noncareer employees (such as, Substitute Rural Carriers, Rural Carrier Associates, Postmaster Leave Replacements, Postal Support Employees, City Carrier Assistants, and Mail Handler Assistants) who meet the following criteria:
    1. Have completed 1 year of continuous employment, disregarding breaks in service of 5 days or less.
    2. Have a predetermined tour of duty.
    3. Have sufficient earnings to cover mandatory withholdings and premium deductions.

521.3 Employees Not Eligible

The following employees, with certain exceptions, are not eligible for health insurance:

  1. Casual and temporary employees (including “off–the–street” officers in charge) serving under an appointment limited to 1 year or less, except as eligible under 521.2. When individuals are hired as casual or temporary employees and they have previously served in a position in the Postal Service or another federal government agency wherein they were covered by the Health Benefits Program, there must be a break of at least 4 days between such service and the casual or temporary appointment.
  2. Substitute rural carriers (except those transferred from positions in which they were insured without a break in service of more than 3 calendar days), rural carrier associates, and rural carrier reliefs who do not meet the criteria noted in 521.2g.
  3. Members of the armed forces.
  4. Noncitizens whose permanent duty stations are located outside the United States or the Panama Canal Zone.
  5. Employees paid on a contract or fee basis except as eligible under 521.2e. Ineligible contract employees include (1) contract job cleaners; (2) special delivery messengers at post offices in Cost Ascertainment Groups (CAG) H through L; (3) clerks–in–charge of rural or contract stations; (4) mail messengers and all other contract carriers; and (5) clerks and leave replacements at Post Offices in CAG L.
  6. Employees whose pay on an annual basis is $350 a year or less or whose salary for the pay period is too small to justify withholdings.
  7. Employees expected to work less than 6 months in each year except as provided in 521.2c and d and employees whose employment is of uncertain or temporary duration or for brief intervals.

521.4 Family Member Eligibility

 

Reference Note:

For more material about the information in 521.4 through 521.5, see:

521.41 General
521.411 Responsibility of Human Resources Shared Service Center

The Human Resources Shared Service Center (HRSSC) is responsible for determining whether or not a person is a family member for health benefits purposes for an enrolled employee. It is that person’s relationship to the employee that is controlling. The HRSSC must satisfy itself that an event has occurred that permits enrollment or a change in enrollment under the Federal Employees Health Benefits (FEHB) Program.

Documentary evidence may be requested as appropriate (e.g., marriage certificate, birth certificate, or divorce decree). However, it is not necessary that such evidence be retained. The carrier is not notified at the time the original determination is made regarding the eligibility status of an enrollee’s family member, but the carrier may request evidence to verify the eligibility of the family member at the time benefits for that family member are claimed.

521.412 Family Members Eligible

The employee’s spouse, including a spouse in a valid common-law marriage, and children under age 26, including legally adopted children, recognized natural (born out of wedlock) children and stepchildren, are eligible for coverage. A child is eligible for coverage under an employee’s Self and Family enrollment, if a state-issued birth certificate lists the employee as a parent of that child.

A child over age 26 who is incapable of self-support because of mental or physical incapacity that existed before the child’s 26th birthday is eligible if the incapacity is established as explained in 526.

Foster Children are included if they meet the requirements listed below:

  1. The child must be under age 26 (if the child is age 26 or over, he/she must be incapable of self-support);
  2. The child must currently live with the employee;
  3. The parent-child relationship must be with the employee, not the child‘s biological parent;
  4. The employee must currently be the primary source of financial support for the child; and
  5. The employee must expect to raise the child to adulthood.

Note: Effective June 26, 2013, legally married same-sex spouses became eligible family members under a Self and Family enrollment. Coverage is available to any legally married same-sex spouse regardless of the employee’s state of residency. In addition, the children of same-sex marriages will be treated in the same manner as those of opposite-sex marriages and will be eligible family members according to the same eligibility guidelines. This includes coverage for children of same-sex spouses as stepchildren.

In accordance with Office of Personnel Management regulations dated October 30, 2013, qualified stepchildren of same-sex domestic partners are eligible family members effective January 1, 2014. This is only applicable to employees living in states that do not allow same-sex marriage.

521.42 Determining Family Membership Status of Children
521.421 Adopted Children

Applicable state law governs whether or not a child has been adopted. The child is considered adopted for health benefits purposes if the adoption decree is final or if it is interlocutory and state law provides that the rights of the child generally are the same as those of an adopted child.

521.422 Stepchildren

If not contrary to state law, an employee’s spouse’s legitimate or adopted child, or natural child, is considered to be the employee’s stepchild. However, a stepchild by a previous marriage of the employee’s spouse is not the employee’s stepchild.

An employee’s stepchild remains a stepchild and an eligible family member after the employee’s divorce from, or the death of, the natural parent, provided that the stepchild continues to live with the employee in a regular parent-child relationship. If the stepchild stops living with the employee in a regular parent-child relationship, the child is eligible for coverage under Temporary Continuation of Coverage (TCC) provisions because he/she no longer meets the definition of an eligible child.

If the employee divorces and the former spouse is eligible to enroll under either the Spouse Equity or TCC provisions, only the natural or adopted children of both the employee and the former spouse are covered under the former spouse’s Self and Family enrollment. An employee’s stepchildren are not covered even though they may have been covered previously by the employee’s Self and Family enrollment. However, they may qualify for a TCC enrollment of their own.

521.423 Foster Children

To be considered a foster child for health benefits purposes, the child must be under age 26, the child must be incapable of self-support, if the child is age 26 or over, the child must live with the employee in a regular parent-child relationship, and the employee must be rearing the child as his or her own. The employee need not be related to the child nor have taken steps to legally adopt the child, but there must be an expectation that the employee will continue to rear the child into adulthood.

  1. The employee must currently be the primary source of financial support for the child. However, a foster parent-child relationship between the child and an employee may exist even though the child receives support from other than the employee (e.g., Social Security payments, support payments from a parent, etc.).
  2. Common examples of a foster parent–child relationship are the following:
    1. A child’s parents have died and the child is living with and supported by a grandparent (or other close relative) who is an employee.
    2. A grandchild is living with an employee who supports the child financially and intends to raise him or her to adulthood. This situation may exist even if one natural parent also lives with the employee and the child.
    3. A child is living with an employee under a preadoption agreement.
    4. A child is in the legal custody of an employee.

    Note: A Certification of Foster Child Status must be signed by the employee and filed as a permanent document in the employee’s official personnel folder. For a sample certification, see Exhibit 521.423.

  3. A child who has been placed in the employee’s home by a welfare or social service agency under an agreement whereby the agency retains control of the child or pays for maintenance does not qualify as a foster child as there is no regular parent–child relationship. Similarly, an arrangement under which a child is temporarily living with an employee as a matter of convenience does not qualify the child as a foster child.
521.424 Child’s Temporary Absence on “Living–With” Requirement

Periods of temporary absence while attending school or for other reasons do not affect the family member status of foster children otherwise considered to be living with the employee in a regular parent-child relationship. Also, an employee’s foster child, who lives with the employee at least 6 months a year under a court order directing shared custody may be considered living with the employee in a regular parent-child relationship.

521.425 Effect of Child’s Marriage on Family Member Status

An employee’s married child is covered under the employee’s Self and Family enrollment until the child reaches age 26. The child’s spouse and/or children are not covered and dual enrollment is prohibited.

521.5 Relatives Not Eligible

The employee’s parents, brothers, sisters, and relatives, except those eligible under 521.4, are not eligible for health benefits coverage as family members even though they may live with and be dependent upon the employee for support.

Exhibit 521.423

Certification for Foster Children

 

Postal Logo

Certification for Foster Children

I have been informed of the following requirements for coverage of a foster child under the Federal Employees Health Benefits (FEHB), Federal Employees’ Group Life Insurance (FEGLI), and the Federal Employees Dental and Vision Insurance (FEDVIP) Programs:

1. For FEHB, the child must be under age 26. If the child is age 26 or older, he/she can only be covered if he/she is incapable of self-support because of a disabling condition that began before age 26. I must provide documentation of this to the Human Resources Shared Service Center (HRSSC);

2. For FEGLI and FEDVIP coverage, the child must be unmarried and under age 22 to qualify for coverage unless he/she is incapable of self-support because of a disabling condition that began before age 22. I must provide documentation of this to the HRSSC;

3. The child must currently live with me;

4. I must currently be the primary source of financial support for the child;

5. The parent-child relationship must be with me and not with the biological parent. This means that I exercise parental authority, responsibility, and control. I care for, support, discipline, and guide the child. I make the decisions about the child’s education and health care; and

6. I must expect to raise the child into adulthood.

I understand that if the child moves out of my home to live with a biological parent, he/she loses coverage and cannot ever again be covered as a foster child unless the biological parent dies, is imprisoned, or becomes incapable of caring for the child due to a disability, or unless I obtain a court order taking parental responsibility away from the biological parent.

This is to certify that [__name of child__] lives with me; I am the primary source of financial support for this child; I have a regular parent-child relationship with this child, as described above; and I intend to raise this child into adulthood.

I have provided my employing agency proof of my regular and substantial support for ____________________________ [name of child].

I will immediately notify both the HRSSC and the health benefits carrier (if this child is covered by FEHB) and/or dental and/or vision insurance carrier (if this child is covered by FEDVIP) if this child moves out of my home, ceases to be financially dependent on me, or otherwise no longer qualifies as a foster child per any of the requirements shown above.

 

_________________________________________________ ________________________________________

Print Name of Employee Employee Identification Number

________________________________________________ ________________________

Employee Signature Date

Privacy Act Statement: Your information will be used to certify that you intend to raise a “foster” child until adulthood for the purposes of coverage under the Federal Employees Health Benefit (FEHB), Federal Employees Group Life Insurance (FEGLI), and Federal Employees Dental and Vision Insurance (FEDVIP) Programs. Collection is authorized by 39 U.S.C. 410, 1001, 1005, and 1206. Providing the information is voluntary, but if not provided, we may be unable to process your request. We may disclose your information as follows: in relevant legal proceedings; to law enforcement when the U.S. Postal Service (USPS) or requesting agency becomes aware of a violation of law; to a congressional office at your request; to entities or individuals under contract with USPS; to entities authorized to perform audits; to labor organizations as required by law; to federal, state, local, or foreign government agencies regarding personnel matters; to the Equal Employment Opportunity Commission; to the Merit Systems Protection Board or Office of Special Counsel; the Selective Service System, records pertaining to supervisors and Postmasters may be disclosed to supervisory and other managerial organizations recognized by USPS; and to financial entities regarding financial transaction issues.

Benefits and Compensation
PO Box 970400
Greensboro NC 27497-0400

USPS 30

 

 

521.6 Former Spouses

 

Reference Note:

For more material about the information in 521.6, see:

521.61 Eligibility Determination
521.611 Requirements

Former spouses of employees are eligible to enroll for health benefits coverage under the Federal Employees Health Benefits (FEHB) Program if they meet all of the following requirements:

  1. Based on a qualifying court order or divorce decree, the OPM has granted the former spouse a portion of the employee’s annuity or a survivor benefit.
  2. The former spouse, if under the age of 55, has not remarried.
  3. The former spouse was covered as a family member in an FEHB plan at any time during the 18 months before the date of the dissolution of marriage.
  4. The application for coverage is filed within 60 days after:
    1. The marriage is dissolved;
    2. The date of OPM’s notice to the former spouse of his/her eligibility to enroll based on a qualifying court order awarding entitlement to a portion of the employee’s future annuity; or
    3. The date of the notice of the former spouse’s eligibility to enroll based on entitlement to a former spouse’s annuity under another retirement system for government employees.

If the application is mailed, the postmark is used in determining the 60-day time limit.

521.612 Office of Personnel Management Responsibility

OPM is responsible for determining whether a former spouse is entitled to receive a survivor annuity or a portion of the employee’s retirement annuity as a prerequisite to the former spouse’s eligibility to enroll in the FEHB Program.

The former spouse forwards the request for determination to:

U.S. OFFICE OF PERSONNEL MANAGEMENT
COURT ORDERED BENEFITS BRANCH
PO BOX 17
WASHINGTON, DC 20044–0017

The request must contain as much information as possible, including the employee’s name, date of birth, Social Security number, and HRSSC address, and a certified copy of the court order or divorce decree.

OPM sends the former spouse a written decision once it has reviewed all the information provided by the former spouse.

521.613 Human Resources Shared Service Center Responsibility

The Human Resources Shared Service Center (HRSSC) is responsible for accepting the former spouse’s application for health benefits coverage under the FEHB Program. The former spouse’s application for health benefits may be in the form of an SF 2809, Employee Health Benefits Election Form, a letter, or a written statement to the HRSSC. The application preserves the former spouse’s FEHB enrollment right until the eligibility determination is made.

After the former spouse provides the HRSSC with a copy of OPM’s decision as required by 521.612, the HRSSC makes its determination regarding the former spouse’s eligibility to enroll under the FEHB Program by verifying whether the requirements stated in 521.611b and 521.611c have been met. To make this determination, the HRSSC:

  1. Reviews the SFs 2809, the SFs 2810, Notice of Change in Health Benefit Enrollment, and the PostalEASE FEHB Worksheets in the employee’s electronic official personnel folder (eOPF) to determine if the former spouse was covered as a family member in an FEHB enrollment at any time during the 18 months before the date of the dissolution of marriage.
  2. Verifies the former spouse’s age and, if under age 55, verifies that the former spouse has not remarried.
521.62 Documentation of Eligibility
521.621 Eligible for Coverage

If the former spouse meets all the requirements stated in 521.61, and is, therefore, eligible for coverage, the HRSSC notifies the former spouse in writing of its determination. The notification of eligibility acknowledges the documents on which the HRSSC based its decision, i.e., proof that the former spouse has not remarried before age 55 and that the former spouse was enrolled under the FEHB Program at some point during the 18 months before a divorce. An RI 70–5, Guide to Federal Benefits for TCC and Former Spouse Enrollees, and a statement of the requirements for continued enrollment (Exhibit 523.62) are forwarded to the former spouse with the notification. See 523.6 for enrollment procedures.

521.622 Ineligible for Coverage

If the HRSSC determines, after its review, that the former spouse has not met the eligibility requirements for health benefits coverage stated in 521.61, it notifies the former spouse of its determination in writing. The notification of ineligibility must provide the former spouse the right to request reconsideration of its decision in accordance with 521.63. It must also state the reason for the denial, specify the time limit for making the reconsideration request, and include the address for forwarding the request (see 521.63).

521.63 Request for Reconsideration

A former spouse denied health benefits coverage by the HRSSC may request reconsideration of the HRSSC’s refusal to permit him or her to enroll. The request is made in writing and sent within 30 days of the HRSSC’s letter of denial to the area Human Resources address identified in the denial letter. Requests must include the employee’s name and date of birth, reasons for the request, and a copy of the denial letter. The decision rendered by the area office is final.

521.7 Temporary Continuation of Coverage

 

Reference Note:

For more materials about the information in 521.7, see:

Specific individuals who lose entitlement to health benefits may qualify to enroll under the Temporary Continuation of Coverage (TCC) Program. This program provides health benefits enrollment opportunities to allow continuation of benefits beyond the 31–day extension period that follows termination. Election is allowed in any plan or option available for which the individual meets the enrollment criteria, if any.

521.71 Eligibility
521.711 Eligible for Coverage

Individuals identified below are eligible to enroll in TCC beyond the 31–day extension period allowed following termination of coverage:

  1. Employees who separate voluntarily or involuntarily, except those who are separated due to gross misconduct.
  2. Annuitants who at time of retirement do not meet the criteria to continue enrollment into retirement.
  3. Children who have been covered under an employee or annuitant’s enrollment because they met the requirements for dependent children and no longer meet these requirements. This group includes children who:
    1. Lose coverage because they reach age 26.
    2. Lose their status as stepchildren or foster children.
    3. Are disabled, age 26 and older, and recover from their disability or become able to support themselves.
    4. Lose coverage upon the death of an employee because he/she does not qualify for a survivor annuity.
  4. Former spouses who are enrolled as family members in FEHB sometime during the 18 months prior to the end of the marriage, but who are not entitled to coverage under the Spouse Equity Act (see 521.611) or who are awaiting approval or disapproval from OPM of entitlement to coverage under the Spouse Equity Act.
521.712 Ineligible for Coverage

Family members are not eligible to continue coverage beyond the 31–day extension period if loss of coverage is due to any of the following:

  1. Employee changes to Self Only or cancels coverage.
  2. Employee serves 12 months in nonpay status.
  3. Annuity is terminated.
  4. OWCP benefits are terminated.
  5. Employee transfers to a position excluded from FEHB.
  6. Widows and/or children do not qualify for survivor benefits.
  7. Survivor annuity or children’s benefits are terminated.
521.72 Agency Responsibilities
521.721 Office of Personnel Management Responsibility

OPM has contracted with the National Finance Center (NFC) to act as the central processing office for the collection of FEHB premiums under the TCC program.

521.722 National Finance Center Responsibility

The NFC:

  1. Establishes and maintain accounts.
  2. Performs billing and collection functions.
  3. Handles FEHB Open Season for TCC enrollees.
521.723 Human Resources Shared Service Center’s Responsibility

The Human Resources Shared Service Center (HRSSC):

  1. Notifies separating employees of conversion rights.
  2. Notifies children and former spouses of conversion rights.
  3. Assists in enrollment in the TCC program.
  4. Forwards enrollment information to the NFC.
  5. Maintains copies of documents regarding TCC enrollment.
  6. Responds to NFC inquiries.

The HRSSC must collect, review, and approve all SF 2809 forms before forwarding the appropriate copies to the National Finance Center (NFC) for processing.

521.73 Time Limitations for Enrollment

SF 2809 forms to enroll in the TCC program must be received by the HRSSC within the specific timeframes noted below:

  1. Former Employees. Forms must be received within 60 days after the date of separation or within 65 days after the date the SF 2810, Notice of Change in Health Benefits Enrollment, is received from the Postal Service, whichever is later.
  2. Children. Forms must be received either:
    1. Within 60 days after the qualifying event, if the employee did not notify the HRSSC within the required 60-day notification period (even if someone else provided notification); or
    2. 65 days after the date the notice is received from the Postal Service, if the employee notified the HRSSC within the required 60-day notification period.
  3. Former Spouses. Forms must be received either:
    1. Within 60 days after the date of divorce or annulment, if the employee or the former spouse did not notify the HRSSC within the required 60-day notification period (even if someone else provided notification); or,
    2. 65 days after the date of the HRSSC’s notice, if the employee or the former spouse notified the HRSSC within the required 60-day notification period; or
    3. 60 days after the date the former spouse lost coverage under Spouse Equity provisions (because of remarriage before age 55 or loss of the qualifying court order), if the loss of coverage is within the 36-month period of TCC eligibility.

If the employee or the former spouse does not notify the HRSSC within the 60-day period, the former spouse’s opportunity to elect TCC ends 60 days after the divorce or annulment.

521.74 Length of Coverage

Generally, coverage begins on the thirty–second day after the qualifying event that terminates enrollment for children and former spouses, allowing for the free 31–day extension of coverage.

Former employees may continue coverage for up to 18 months from the separation date; children and former spouses may continue coverage for up to 36 months from the date of the qualifying event. Coverage may end sooner if the individual fails to pay premiums, voluntarily cancels coverage, or again acquires coverage under the regular FEHB provisions.

521.75 Premiums

TCC enrollees pay the full premium cost (both the employee and Postal Service shares) plus a 2 percent administrative surcharge. All premiums are made by coupon payment and in accordance with a schedule as directed by NFC.